MDS 2026 — Freezing of Gait and Postural Instability in Parkinson's Disease

Congress: Movement Disorder Society (MDS) International Congress 2026 Dates: October 4-8, 2026 Location: Seoul, Korea — COEX Convention and Exhibition Center Theme: Understanding Aging in Movement Disorders

Overview

Freezing of gait (FOG) and postural instability represent two of the most disabling features of advanced Parkinson's disease (PD), contributing significantly to falls, functional decline, and reduced quality of life. These axial symptoms often respond poorly to dopaminergic therapy and remain major unmet needs in PD management["@nutt2011"][@nonnekes2018].

Congress: Movement Disorder Society (MDS) International Congress 2026 Dates: October 4-8, 2026 Location: Seoul, Korea — COEX Convention and Exhibition Center Theme: Understanding Aging in Movement Disorders

Overview

Freezing of gait (FOG) and postural instability represent two of the most disabling features of advanced Parkinson's disease (PD), contributing significantly to falls, functional decline, and reduced quality of life. These axial symptoms often respond poorly to dopaminergic therapy and remain major unmet needs in PD management["@nutt2011"][@nonnekes2018].

MDS 2026 will feature dedicated sessions addressing the latest advances in understanding, assessing, and treating freezing of gait and postural instability in Parkinson's disease and related disorders.

Freezing of Gait in Parkinson's Disease

Definition and Clinical Impact

Freezing of gait is defined as a sudden, transient inability to generate effective stepping, despite the intention to walk[@giladi1992]. Patients describe their feet as feeling "glued to the floor" — a phenomenon that significantly increases fall risk and contributes to loss of independence.

Key statistics:

• Prevalence: 50-70% of patients with advanced PD
• Major cause of falls and functional decline
• Often resistant to dopaminergic therapy
• Strongly associated with cognitive impairment

Classification of Freezing

| Type | Clinical Features | Response to Treatment |
|------|-------------------|----------------------|
| Off-period freezing | Occurs during "off" states, improves with dopaminergic therapy | Good response to medication adjustment |
| On-period freezing | Occurs during "on" states, often medication-resistant | Poor response to dopaminergic therapy |
| Mixed freezing | Both off-period and on-period episodes | Variable response |
| Start hesitation | Difficulty initiating first step | May respond to cueing |
| Turn-freezing | Freezing specifically during turns | Often refractory to treatment |

Triggers and Provoking Factors

Freezing episodes are often triggered by specific conditions:

• Narrow spaces: Doorways, hallways, crowded areas
• Transitions: Starting to walk, turning, stopping
• Dual-tasking: Walking while talking, carrying objects
• Visual challenges: Dark environments, uneven surfaces
• Emotional stress: Anxiety, hurrying

Pathophysiology

The neural mechanisms underlying freezing of gait involve dysfunction in multiple neural networks:

Central Mechanisms

| Region | Role in Gait Control | Dysfunction in FOG |
|--------|---------------------|-------------------|
| Pedunculopontine Nucleus (PPN) | Gait initiation, postural control | Cholinergic neuronal loss, tau pathology |
| Basal Ganglia | Motor sequencing, automatic movement | Dopaminergic denervation, altered output |
| Supplementary Motor Area | Motor planning, self-initiated movement | Reduced activation during self-initiated steps |
| Frontal Cortex | Executive function, obstacle avoidance | Executive dysfunction, impaired conflict resolution |
| Cerebellum | Motor coordination, adaptive learning | Aberrant cerebellar activity during freezing |

Neurotransmitter Systems

• Dopaminergic: Nigrostriatal degeneration contributes to FOG, but dopamine alone often insufficient
• Cholinergic: PPN degeneration is a key substrate, explaining limited levodopa response
• Noradrenergic: Locus coeruleus dysfunction affects arousal and attention during gait
• Serotonergic: Raphe nuclei involvement may contribute to gait automatization deficits

Neuroimaging Findings

• MRI: May show reduced pedunculopontine nucleus volume, white matter changes
• DaTscan: Reduced dopamine transporter uptake in striatum correlates with FOG severity
• FDG-PET: Hypometabolism in frontal cortex, PPN, and cerebellum
• DTI: Damage to frontal pathways and pontine reticular formation

Assessment Tools

Clinical Scales

| Scale | Description | Clinical Use |
|-------|-------------|---------------|
| New Freezing of Gait Questionnaire (NFOGQ) | Self-reported FOG severity and impact | Baseline and follow-up |
| MDS-UPDRS Part III Item 11 | examiner-rated freezing | Routine clinical assessment |
| Timed Up and Go (TUG) | Functional mobility, includes turn component | Screening for fall risk |
| 6-Minute Walk Test | Walking endurance | Functional capacity |

Objective Assessments

• Wearable inertial sensors: Quantify freezing episodes, step length, cadence
• Instrumented walkway: Pressure-sensitive mat analysis
• Video analysis: Document trigger patterns
• Digital biomarkers: Continuous monitoring in daily life

Postural Instability in Parkinson's Disease

Clinical Features

Postural instability is the loss of postural reflexes leading to impaired balance and increased fall risk. It typically develops later in the disease course but represents a major cause of morbidity.

Core manifestations:

• Retropulsion (backward falling)
• Inability to recover from perturbations
• Frequent falls, often with injury
• Fear of falling (kinesophobia)

Assessment

Standardized Tests

| Test | Description | Scoring |
|------|-------------|---------|
| Pull Test | Examiner pulls shoulders, observes recovery | 0-3 scale (MDS-UPDRS) |
| Berg Balance Scale | 14 functional balance tasks | 0-56 score |
| TUG Test | Timed up, walk 3m, turn, return, sit | <13.5s normal |
| Mini-BESTest | Dynamic balance assessment | 0-28 score |
| Pusher Scale | Assessment of lateral pushing behavior | 0-12 score |

Pathophysiology

• Basal ganglia dysfunction: Altered postural tone regulation
• Brainstem involvement: Nucleus gigantocellularis, vestibular nuclei
• Cholinergic deficits: PPN and basal forebrain degeneration
• Sensorimotor integration: Impaired proprioceptive processing
• Cognitive contribution: Visuospatial dysfunction, attention deficits

Management Strategies

Pharmacological Approaches

• Dopaminergic therapy: Limited benefit for postural instability
• Methylphenidate: May improve gait and postural control in advanced PD
• Rivastigmine: Cholinesterase inhibitor may enhance postural stability
• Atomoxetine: Norepinephrine reuptake inhibitor under investigation

Non-Pharmacological Interventions

• Balance training: Task-specific balance exercises
• Strength training: Lower extremity and core strengthening
• Tai Chi: Shown to improve balance and reduce falls
• Dance therapy: Particularly tango-based programs
• Aquatic therapy: Reduces fall risk in controlled environment
• Home safety modification: Remove hazards, install grab bars

Emerging Therapies and Research Directions

Pharmacological Developments

| Agent | Mechanism | Development Stage | Target |
|-------|-----------|-------------------|--------|
| Talispring (ABBV-951) | Levodopa/carbidopa subcutaneous | FDA approved | Motor fluctuations |
| ABBV-663 | Alpha-synuclein aggregation inhibitor | Phase 2 | Disease modification |
| Prasinezumab | Anti-alpha-synuclein antibody | Phase 2 | Disease modification |
| Lixisenatide | GLP-1 receptor agonist | Phase 2 | Motor progression |
| Inotersen | Anti-tau oligonucleotide | Preclinical | Tauopathy |

Device-Based Therapies

• Adaptive DBS: Closed-loop systems that respond to real-time movement
• Wearable cueing devices: Vibrotactile feedback during freezing
• Functional electrical stimulation (FES): Foot drop correction
• Exoskeletons: Gait assistance in advanced disease

Rehabilitation Approaches

• Virtual reality training: Immersive balance exercises
• LSVT BIG therapy: Amplified movement training
• Treadmill training with constraints: Split-belt treadmill
• Cueing strategies: Personalized multimodal cueing systems

Research Priorities

MDS 2026 Expected Sessions and Topics

Anticipated Presentations

• Updated understanding of neural circuits
• Novel therapeutic targets
• Clinical trial design challenges

• Evidence-based rehabilitation approaches
• Fall risk stratification
• Multidisciplinary care models

• Cholinergic dysfunction in gait disorders
• PPN stimulation outcomes
• Optimal targeting strategies

• Continuous monitoring of axial symptoms
• Real-time freezing detection
• Remote patient monitoring

• Cholinergic agents
• Noradrenergic modulation
• Combination strategies

Learning Objectives for Delegates

• Understand the neurobiological basis of freezing of gait and postural instability
• Apply evidence-based assessment tools in clinical practice
• Implement current management strategies
• Identify emerging therapies and clinical trial opportunities
• Recognize when surgical intervention is indicated

Related Pages

• [MDS 2026 — Main Congress Page](/events/mds-2026)
• [MDS 2026 — Parkinson's Disease Sessions](/events/mds-2026-parkinsons-sessions)
• [MDS 2026 — Motor Complications](/events/mds-2026-parkinsons-motor-complications)
• [MDS 2026 — Emerging Therapeutics](/events/mds-2026-parkinsons-emerging-therapeutics)
• [MDS 2026 — Parkinson's Disease](/events/mds-2026-parkinsons-sessions)
• [Freezing of Gait in Parkinson's](/diseases/freezing-gait-parkinsons)
• [Pure Akinesia with Gait Freezing](/diseases/pure-akinesia-gait-freezing)
• [Parkinson's Disease](/diseases/parkinsons-disease)
• [Pedunculopontine Nucleus](/brain-regions/pedunculopontine-nucleus)
• [Postural Instability in Parkinson's](/diseases/parkinsons-disease#postural-instability)
• [Balance Disorders in Atypical Parkinsonism](/diseases/gait-balance-disorders-cbs)
• [Physical Therapy for Parkinson's](/therapeutics/physical-therapy-parkinsons)
• [Deep Brain Stimulation for Parkinson's](/therapeutics/deep-brain-stimulation-parkinsons)

External Resources

• [MDS Congress 2026](https://www.mdscongress.org)
• [International Parkinson and Movement Disorders Society](https://www.movementdisorders.org/)
• [Parkinson's Foundation - Freezing of Gait](https://www.parkinson.org/Life-with-Parkinsons/Movement-Symptoms/Freezing)
• [Parkinson's Foundation - Balance and Falls](https://www.parkinson.org/Life-with-Parkinsons/Movement-Symptoms/Balance)
• [European Physiotherapy Guideline for Parkinson's Disease](https://www.appdeurope.com/)

References